Download Toward the Treatment of Co-Occurring Conditions: Multiple

Outline
Toward the Treatment of
Co-Occurring Conditions:
Multiple Condition Care
• The Problem as Semantics
– The Problem from the CD Care Perspective
– The Problem from the MI Care Perspective
• The Problem as Prevalence and Incidence
• What To Do: The Basics of Multiple Condition
Care
• Meeting Objections
• Mental Illness and Types of Drugs
• How To Begin?
G. Scott Schleifer, Ed.D., L.P.
Anoka Metro Regional Treatment Center
March 2005
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The Problem as Semantics
The Problem
• Traditionally, the treatment of mental illness and
chemical dependency have taken place in separate
settings, using different models of care.
• The treatment of mental illness is rooted in
medicine, and the lead provider is a psychiatrist or
psychologist.
• The treatment of chemical dependency has
intentionally non-professional roots, and the lead
provider often is a peer or a counselor.
• A large number of clients arriving for services
have problems of both mental illness and
substance abuse.
• These people need something that can address
both of these conditions.
• Traditional MI/CD care always has had a stronger
focus on one or the other areas; either the MI or
CD was treated, with the other condition “tacked
on,” almost as an afterthought depending on where
the client entered the care delivery system.
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The Problem From the
CD Care Perspective
The Problem from the
MI Care Perspective
• In the early days of the Alcoholics Anonymous
movement (and the similar self help organizations
that followed) chemically dependent people who
were themselves recovering, formed the
overwhelming majority of those providing care.
• Recovering individuals often did not trust
professionals to understand their addiction or even to
have their best interest at heart.
• Tradition Number 8 of Alcoholics Anonymous states
that AA “…should remain forever nonprofessional…” (emphasis added).
• Mental health care has evolved from a medicallybased model of illness to a discipline that also
incorporates social learning and behavioral control
perspectives.
• Substance abuse has been seen as attempts at selfmedication, or as having psychodynamic causes
(such as thanatogenic urges) that underlie it.
• Mental health care providers are professionals,
who sometimes disparage self help models; some
look at AA as “ritual substitution.”
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Commonalities Between Mental Illness
and Chemical Dependency Language
Has Been Recognized (Minkoff)
These Competing Viewpoints
Have Resulted In
• Split care delivery systems in terms of diagnostic
criteria, etiological understanding, funding
streams, and different regulatory environments.
• Seemingly irreconcilable philosophies if not
necessarily the methodologies.
• Mutual suspiciousness of the other system, and
lack of acceptance/respect for peers and
counterparts.
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ALCOHOLISM/ADDICTION
A biological illness.
Hereditary (in part).
Chronicity
Incurability
Leads to lack of control of behavior and
emotions
6.
Affects the whole family
7.
Symptoms can be controlled with proper
treatment
8.
Progression of the disease without
treatment
9.
Disease of denial
10. Facing the disease can to lead to
depression and despair.
11. Disease is often seen as a “moral issue,”
due to personal weakness rather than
biological causes
12. Feelings of guilt and failure
2005 of shame and stigma
13.March
Feelings
14. Physical, mental, and spiritual disease
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
A biological illness.
Hereditary (in part).
Chronicity
Incurability
Leads to lack of control of behavior and
emotions
Affects the whole family
Symptoms can be controlled with proper
treatment
Progression of the disease without
treatment
Disease of denial
Facing the disease can to lead to
depression and despair.
Disease is often seen as a “moral issue,”
due to personal weakness rather than
biological causes
Feelings of guilt and failure
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Feelings of shame and stigma
Physical, mental, and spiritual disease
There Also Are Marked Differences
in Philosophical Orientations
But the Different Language
and Perception Remains
Psychiatry/Psychology
Calls It
Care
Resistance
Symptom substitution
Social learning
Adjustment/learning
Pygmalianism,
Redintigration,
Thanatopsis
MAJOR MENTAL ILLNESS
1.
2.
3.
4.
5.
(From Minkoff)
Mental Health
Community
Chemical Dependency
Calls It
∆ Treatment
∆ Denial
∆ Cross addiction
∆ Enabling
∆ Recovery
∆ Self-Defeating,
Scripting,
Addictive Personality
• Medical/Professional
Model
• Scientific Treatment
• Medication
• Deinstitutionalization
Ideology
• Substance use is
secondary to
psychopathology
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The Problem as
Prevalence and Incidence
Chemical Health
Community
•
•
•
•
•
Peer Counselor Model
Spiritual Recovery
Self-Help
Recovery Ideology
Psychopathology is
secondary to addiction
These can form barriers to
integrated treatment
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Overlap of Mental Illness and
Substance Use Disorders
• Generally accepted that having a mental
illness increases the risk of a substance use
disorder
• Having an addictive disorder multiplies the
risk of a worsening mental illness:
Non-addictive
Psychiatric
Disorders
Substance
Use
Disorders
– Even though the mental illness usually precedes
the substance use disorder
– As therapeutic medications become replaced by
addictive substances or chemicals of abuse
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The Problem as
Prevalence and Incidence
The Problem as
Phenomenology
Lehman identified a number of complicating factors in the
dual diagnosis population:
1. Acute and chronic substance use can produce psychiatric
symptoms
2. Substance withdrawal can cause psychiatric symptoms
3. Substance use can mask psychiatric symptoms
4. Psychiatric disorders can mimic symptoms associated
with substance use
5. Acute and chronic substance use can exacerbate
psychiatric disorders
6. Acute and chronic psychiatric disorders can exacerbate
the recovery process from addictive disorders
• Individuals with multiple conditions are
more likely to seek or be committed to
treatment than those with single disorders
• A large proportion – at AMRTC it’s about
70% – of individuals receiving inpatient
care are both mentally ill and abusing
substances when they are admitted
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The Problem as
Phenomenology
The Problem as
Phenomenology
This leads to:
• Increased vulnerability to relapse and repeated
hospitalization
• More florid psychotic symptoms
• Inability to manage finances and live independently
• Housing instability and homelessness
• Noncompliance with medications and treatment
• Increased vulnerability to HIV infection and
hepatitis, as well as less lethal opportunistic diseases
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So, What to Do:
The Basics of Multiple Condition Care
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So, What to Do:
The Basics of Multiple Condition Care
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Integrated treatment
Individualized treatment planning
Assertiveness
Close monitoring
Longitudinal perspective
Harm reduction
Stages of change
Stable living situation
Cultural competency and consumer centeredness
Optimism
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Multiple conditions often produce:
• Lower satisfaction with familial relationships
• Lowered ability to sustain social relationships
• Increased family burden
• Increased risk of violence, either committed or
received
• Increased risk of incarceration
• Increased depression and suicidality (often
accompanied by episodes of SIB and parasuicidality)
• Higher service utilization and costs
Principles Identified by Sciacca and Others
Principles identified by Schultz and Others
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Integrated (versus collaborative) treatment
Engagement of all clients to the extent possible
Non-theory-dependent screening
Differentiation of persons with multiple disorder and identification
of their service needs
Assessment of client readiness and adjustment to care accordingly
Educated, cross-trained providers
Acceptance, empathy and non-confrontation
Continuity of care extends into the entire community
Outcome measures for staff
Support for family and friends of the patient
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So, What to Do:
The Basics of Multiple Condition Care
Principles identified by Minkoff (broad overview)
• Integration is common to all approaches.
Whenever disciplines work separately, something
falls short. Likewise, consultative models create
inequities and holes in the system.
• Stabilization of the active symptoms is essential
for any further progress. The argument over what
disease is primary often takes place over this
issue. Stabilization across conditions is needed.
• Engagement must be developed as the client
becomes stable in his/her presentation.
• PHASE 1: Stabilization
- Stabilization of active substance use or acute psychiatric symptoms
• PHASE 2: Engagement/Motivational Enhancement
- Engagement in treatment
- Contemplation, Preparation, Persuasion
• PHASE 3: Prolonged Stabilization
- Active treatment, Maintenance, Relapse Prevention
• PHASE 4: Recovery & Rehabilitation
- Continued sobriety and stability
- One year - ongoing
Note: Dr. Minkoff has a detailed implementation
system that this summary does not capture.
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Creating a Common System
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Creating a Common System
• Assertive Care and Monitoring is referenced by
many systems using those words, and others
indirectly. It takes active treatment a step farther,
going to the client’s own world, when necessary.
In practice, this follows a continuum from
response to pagers to ACT teams.
• Long Term Perspective is necessary at all levels
of care. Defining success or failure in the short
term is risky at best, and often is demoralizing and
self defeating.
• Truly Individualized Treatment Planning
– Evaluate and assess most pressing needs
– Determine motivation/ability to address substance
use/mental health problems
– Select target behaviors for change
– Determine interventions to achieve desired goals
– Choose measures to evaluate the intervention
– Select follow-up times to review the plan.
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Creating A Common System
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Creating a Common System
Creating a Common System
• Harm Reduction is a natural consequence
of taking a long term perspective. Minkoff
has discussed the role of wet and damp
houses in the continuum of care, for
example. And the Harm Reduction model
can be found – albeit often disguised – in
“main stream” CD treatment with mood
stabilizing medication, for example.
• Cross Trained Providers are essential to
any comprehensive system of multiple
condition care. CD professionals must
understand the role of mental illness, and
the medications involved in treating that
illness. Mental health professionals must
truly view their CD colleagues as peers, and
have respect and understanding for the
addictive urges and relapses the client faces.
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Creating a Common System
Creating a Common System
• Extended Support both for the client, and
for the family and friends, as well as
extending the continuity of care into the
community. This includes:
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• Feedback and Evaluation should be built
into the system. Staff need to see what they
do well and where they can do better so that
feedback is an opportunity for growth and
not a source of threat.
• Hope and Optimism should be evident for
both clients and staff.
Stable living situation
Availability of psychiatric care
Availability of CD recovery support
Support in finances and work
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Staffing an Integrated Team
Staffing an Integrated Team
(SAMHSA Recommended)
The following should be included in the team:
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Behavior Analyst
Behavioral Technician/Milieu Staff
Chemical Dependency Counselor
Nurse
Occupational Therapist
Psychiatrist
Psychologist
Social Worker
Spiritual Care Person (Clergy, Imam, Monk, Priest, etc.)
Vocational Counselor
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Inpatient Inpatient Inpatient Intensive
“Regular”
Closed
Open
CD
Outpatient
Outpatient
3:1
5:1
5:1
4-6 per FTE 16-30 per FTE
And of course, Self Help groups have zero staff.
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Meeting Objections
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Meeting Objections
• Enabling. Some see assertive multiple condition
care as enabling maladaptive behavior. Some see
preference of empathic approaches as “too soft” and
do not wish to give up confrontational methods.
– Some clients will try to violate boundaries, and
manipulate you. That is part of their illness.
– Empathic approaches model desired behaviors and help
the client to learn new responses
– Empathy does NOT mean giving up one’s boundaries.
One does not need to use confrontive approaches to
establish or maintain those limits.
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Case
Management
15-30 per FTE
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• Harm Reduction and Abstinence. Some object
to the harm reduction model being applied,
favoring traditional abstinence instead.
– Harm reduction can take place any time, anywhere
– Harm reduction can improve the client’s sense of
success and hopefulness when facing shortfalls in
his/her goals
– Harm reduction, when consistently applied, leads to
abstinence in many cases (New Hampshire-Dartmouth
ACT Team study)
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Mental Illness and Type of Drugs
Meeting Objections
• It is tempting to associate certain drugs with
certain types of mental illness.
• Theoretical Fidelity. Some argue that theoretical fidelity
must be maintained for maximum effect. Theoretical
fidelity is most important if you are engaged in academic
research comparing methods, but in the applied world,
many practitioners are more pragmatic that that. People in
the situation easily can make use of theories and methods
that may be conflicting. For example:
– Bipolar patients sometimes use excess alcohol during
depressive phases, and marijuana during manic phases
– Major depression patients tend to make use of
depressants like alcohol, when they have co-occurring
anxiety; and stimulants such as cocaine and marijuana
when there is no concomitant anxiety.
– PTSD often co-exists with high use of alcohol. Indeed,
sobriety often increases experiences of anxiety,
flashback and dissociation, at least early in recovery.
– Use of the Myers-Briggs Type Indicator by non-analysts
– Use of CD recovery language to describe social interactions of
mentally ill people
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March 2005
Specific Drugs and
Mental Illness: Alcohol
Mental Illness and Type of Drugs
• Alcohol is common use in all segments of the population.
Among the seriously and persistently mentally ill (SPMI),
it produces more difficulty than in the general population.
• As a general rule, the SPMI need less alcohol to reach the
level of disinhibition.
• The sedating effects of alcohol may be exaggerated by
prescribed medication.
• Prescribed medication also may affect the degree of
alcohol tolerance as well as the withdrawal effects.
• Some drugs appear to be less related to
specific mental illness.
– Methamphetamine seems to cut across many
sectors.
– Designer drugs, such as ecstasy, seem more
associated with certain lifestyles than types of
illness.
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Specific Drugs and
Mental Illness: Alcohol
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Specific Drugs and
Mental Illness: Alcohol
• Detoxification risks increase with many medications
associated with SPMI. Medical detoxification
regimens are necessary to retain safety.
• Chronic alcohol use increases SPMI risks
– Greater risk to the liver
– Greater risk of mental impairment or dementia
– Risk of potentiation effects between alcohol and
prescribed medications, including overdose risks
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• Some persons with SPMI go off of their
prescribed medications in order to drink
– The original symptoms re-emerge
– These symptoms are complicated by alcoholic effects
• Risky behaviors
• Aggressive behaviors
• Lack of responsibility
• Both the SPMI and alcohol abuse must be
addressed when the individual returns to the care
delivery system
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Specific Drugs and
Mental Illness: Alcohol
Specific Drugs and
Mental Illness: Alcohol
• Some medications can be of assistance to helping
those with SPMI to deal with alcohol desires
• Should those with SPMI ever drink?
– The stakes are very high
– By some statistics, those with SPMI are 9 times more
likely to develop alcohol related disorder than the
general population
– A very high proportion of those returning to care as a
result of provisional discharges used alcohol just prior
to their readmission
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– Disulfiram (Antabuse) can help in the short term, for
the individual to establish new habits. Compliance
issues arise in the long term.
– Naltrexone (Revia) can help indirectly, by acting on the
pleasure centers, and reducing cravings
• Certain medications, such as benzodiazepines,
should be considered very carefully before their
prescription, due to cross dependency effects
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Specific Drugs and
Mental Illness: Alcohol
Specific Drugs and
Mental Illness: Cannabis
• Cannabis, in the form of ground leaf marijuana, or in
the more concentrated form of hashish, is common in
the culture to the point that it carries little stigma.
Even though it remains illegal in most settings, many
people consider it to be acceptable “main stream”
behavior to use it.
• Cultural ambivalence is evident. Law enforcement
still interdicts marijuana, while at the same time,
public figures such as Jay Leno (who uses no mood
altering substances himself) and Kevin Eubanks make
jokes about routine use.
One last word of caution
that those with SPMI
often must be reminded:
Beer is alcohol.
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Specific Drugs and
Mental Illness: Cannabis
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Specific Drugs and
Mental Illness: Cannabis
• Cannabis is absorbed into fat cells, and thus remains in the
system for weeks after the last use. This can reduce
detoxification risks, as the substance is removed gradually.
This effect may reduce the effects of withdrawal. It also can
complicate the clinical picture for those with SPMI.
• There is no evidence that cannabis actually causes mental
illness, although a user may exhibit symptoms that mimic
mental illness while intoxicated. That said, cannabis is a
stressor to the system, and can evoke symptoms of mental
illness in those who are so predisposed.
• Long term cannabis use degrades the immune system, can
lead to cardiac and pulmonary problems, and disrupts
hormone production. It also reduces cognitive functioning
and attention span.
• The principal active ingredient in marijuana
(THC) is considered to be a mild hallucinogen.
It is not addictive in the classical sense, but can
foster psychological dependence easily.
• Even in people with no mental illness, THC can
evoke feelings of paranoia, isolation, and
delusion.
• Because marijuana is illicit, there is no standard
dosage or quality. Street marijuana also can
contain additives that are harmful in themselves.
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Specific Drugs and
Mental Illness: Cannabis
Specific Drugs and
Mental Illness: Stimulants
• Treatment of co-existing SPMI and cannabis
dependence is challenging. The user often
resists medication, or “forgets” to follow the
prescribed treatment.
• Differentiation can take place by noting the
symptom complex after detoxification. If
symptoms persist, that suggests that the
individual either already had or was predisposed
to mental illness.
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• Stimulants are currently are a popular item of abuse.
• Current common stimulants of abuse include:
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Amphetamine
Caffeine
Cocaine
Dextroamphetamine
Ecstasy (MDMA)
Ephedrine
Methamphetamine
Methylphenidate
MDA
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Specific Drugs and
Mental Illness: Stimulants
Specific Drugs and
Mental Illness: Stimulants
• Stimulants produce temporary arousal of the nervous
system. Some stimulants also tend to produce a feeling of
euphoria.
• At higher doses, hyper-arousal takes place including:
• The typical pattern of stimulant abuse is to ingest stimulants
with enough frequency so as to maintain a “high” while
avoiding the episodes of depression that follow heavy use.
• These episodic periods of use are called “runs” and may last
for several days without sleep, followed by a “crash.”
• Following the stimulant crash, there typically is a period of
intense craving. The user may become involved in criminal
activities in order to finance repeated drug purchases.
– Hyper-awareness
– Hyper-vigilance
– Hyper-sexuality
• At very high doses, the individual is subject to confusion,
disorientation, and cardiac arrhythmia.
• Episodes of mania or psychosis can be precipitated by
stimulants, and depression often follows episodes of
stimulant intoxication.
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Depression
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Specific Drugs and
Mental Illness: Stimulants
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High
Crave
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Specific Drugs and
Mental Illness: Opiates and Opioids
• Stimulant abuse exacerbates any existing mental illness. The
results easily can be disastrous, even in modest use patterns.
• Stimulant abusers typical also abuse sedating drugs to moderate
stimulant effects, as well as drugs of opportunity. This
increases the risk of polysubstance dependence.
• Detoxification can take weeks. Some stimulants can produce
permanent ablation of critical nervous transmission areas of the
brain. Substances such as methamphetamine can produce a
mental sensation often called “fuzz” that can last for years.
• Effective treatment usually involves cognitive behavioral
methods
• Opiates are natural drugs derived from the opium poppy
and include such substances as morphine and codeine.
• Opioids are synthetically produced extensions of or
alternates to opiates. This includes such substances as
heroin and oxycontin.
• These substances initially were used medicinally. For
example, heroin originally was a registered brand name of
a substance developed by Bayer Pharmaceuticals and sold
over the counter for years.
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Specific Drugs and
Mental Illness: Opiates and Opioids
Specific Drugs and
Mental Illness: Opiates and Opioids
• These substances produce responses that are analogous
to natural endorphins. In modest doses, they can
alleviate pain, but because they also evoke strong
feelings of pleasure, they quickly and easily can become
objects of abuse and addiction.
• Users appear calm, even stuperous to the observer. As
the substance begins to wear off, the individual become
anxious, agitated, depressed, and may begin to go into
withdrawal.
• Withdrawal symptoms can be overwhelmingly taxing.
These include dysphoria, aches (including bone aches),
cramps, diarrhea, hyperactivity, restless or kicking legs,
and other similar events.
• Individuals with mental illness are at very high risk of
decompensation when using opiates or opioids.
• Opioid agonist therapy (using methadone, buprenorphine,
or LAAM) is very useful and effective with addicts who
are not mentally ill. However, agonist approaches have
not been well studied among the mentally ill. Clinical
experience suggests the need for very close monitoring of
individuals with SPMI who make use of agonist therapy.
• Certain therapies themselves pose a risk. For example,
some making use of methadone have been found selling
their emesis to addicts.
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How To Begin?
• First, we must establish communication and
cooperation among ourselves. Psychiatrists must
talk with psychologists. Psychologists must talk
with Chemical Dependency Counselors.
Chemical Dependency Counselors must talk with
Social Workers.
• All of the provider community must talk with selfhelp groups like AA, and advocacy groups like
NAMI.
• We all must communicate with the client and
his/her significant others.
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How To Begin?
• We must meet the client where s/he is
today, and work from there.
• We must work within the social and
political systems to improve stable housing
options.
• We must remain hopeful and optimistic.
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